MedicaidCoverageHigh impact

Newsletter Vol. 2, No. 55

Q: Who is affected by this change?

This affects New Jersey Medicaid Occupational Therapy, Physical Therapy, Speech Therapy, Psychiatry, Podiatry, Optometry providers in NJ on Medicaid plans.

New Jersey Medicaid·NJ · Occupational Therapy, Physical Therapy, Speech Therapy +3 more·Provider Notice

Effective date

Not stated

We identified it

Jun 20, 2026

Days to comply

—

Summary

This policy defines covered and non-covered services for Medicaid recipients enrolled in HIP of New Jersey (an HMO) in Burlington, Gloucester, and Hudson counties. Key billing impact: claims for non-emergency HIP-covered services billed to members with restricted HMO cards will be denied with error code; emergency care authorization rules and benefit exhaustion procedures are outlined; dental, orthotics, hearing aids, prescription drugs, and family planning services are NOT covered by HIP and must be billed to Medicaid fiscal agent instead.

Action Required

Action needed

Immediately: (1) Billing team must verify HIP of New Jersey member eligibility and card type (restricted vs. standard) BEFORE billing any services. (2) Configure billing system to route non-covered services (dental, orthotics, hearing aids, prescriptions, family planning, chiropractic, medical day care) to Medicaid fiscal agent, NOT to HIP. (3) For HIP-covered services, obtain prior authorization from HIP Medical Group before service delivery, except in life-threatening/organ-threatening emergency situations within 5-mile radius of HIP facilities (no prior auth required; notify HIP within 24 hours). (4) Implement process to track benefit exhaustion and identify when maximum annual limits are reached (home health, rehabilitative services, mental health inpatient/outpatient, skilled nursing facility); when exhausted, submit 'Exhaustion of Benefits' form from HIP with all claims to Medicaid fiscal agent for continued fee-for-service coverage. (5) Emergency claims (in-network or out-of-area) must be submitted directly to HIP at Horizon Center, Route 1, Robbinsville NJ 08691. (6) Configure system to deny/reject claims with error code when services billed to restricted HMO cards are non-emergency HIP-covered services. Failure to follow these rules will result in claim denials and no payment.

Related policy hubs

New Jersey Medicaid policies NJ policy changes Occupational Therapy Physical Therapy Speech Therapy Psychiatry Podiatry Optometry